Download The Impact of Arterial Hypertension on Right Ventricular Deformation

The Impact of Arterial
Hypertension on Right
Ventricular Deformation
Krasimira Hristova, MD
National Heart Hospital
Department of Noninvasive Cardiovascular Imaging
and Functional Diagnostic
Sofia , Bulgaria
06.04.2012
•
Conflicts: None
Why we should measure the RV function ?
•
-
RV function may be impaired from :
PAH
Acute/ chronic PE
CHD
Valvular heart diseases
LV dysfunction
Secondary from coronary heart diseases,
cardiomyopaties
- AH
Why we should measure the RV
function?
▶RV is not just a conduit of blood flow
: has its unique function
▶ Prognostic significance in various
clinical settings
▶ Risk stratification or guide to optimal
therapy
RV function and prognosis
▶ RV ejection fraction: an indicator of increased
mortality in patients with CHF associated with CAD
(Polak et al. J Am Coll Cardiol 1983)
▶ RV function predicts exercise capacity and survival in
advanced heart failure
(Di Salvo et al. J Am Coll Cardiol 1983)
▶ RV function is a crucial determinant of short-term
prognosis in severe chronic heart failure
(Gavazzi et al. J Heart Lung Transplant 1997)
RV function and prognosis
▶ RV ejection fraction: independent predictor of survival
in patients with moderate heart failure
(De Groote et al. J Am Coll Cardiol 1998)
▶ RV function predicts prognosis in patients with
chronic pulmonary disease
(Burgess et al. J Am Soc Echocardiogr 2002)
▶ RV contractile reserve is associated with one year
mortality in patients with DCMP
(Otasevic et al. Eur J Echocardiography 2005)
Doppler Echocardiography:
Tissue Doppler Imaging
▶ Allows
quantitative assessment of RV systolic and diastolic
function by measurement of myocardial velocities
▶ Peak systolic velocity (PSV)
: PSV < 11.5 cm/s identifies the presence of RV dysfunction
: Sensitivity of 90%, specificity of 85%
: Less affected by HR, loading condition, and degree of TR
▶ Tricuspid lateral annular velocities
: Reduced in patients with inferior MI and RV involvement
: Associated with the severity of RV dysfunction in patients
with heart failure
Normal RV Regional Function
RV longitudinal motion
Colour
Doppler
Pulsed
Doppler
s
s
(4CH view)
RV free wall
e a
e a
Normal RV Regional
Function
RV longitudinal motion
Systolic ring excursion vs ring velocity
Mmode
annular
motion
Tricuspid ring
s
e
a
DMI
annulаr
velocity
Doppler Echocardiography:
Strain Rate Imaging
▶ RV longitudinal strain in apical view
: Feasible in clinical setting
: Baso-apical gradient with higher velocities at the base
: RV velocities are consistently higher as compared to
LV
▶ Strain and strain rate values
: More inhomogeneously distributed in the RV
: Reverse baso-apical gradient, reaching the highest
values in the apical segments and outflow tract
▶ Acute increase in RV afterload
: Increase in RV myocardial strain rate
: Decrease in peak systolic strain, indicating a
decrease in SV
Normal RV Longitudinal Deformation
Strain rate
2
1
Strain
0
0
-1
-2
apica
l
-20
-40
2
0
1
0
-20
medial
-1
-40
-2
2
RV
lateral wall
0
1
0
-20
basal
-1
-2
Mean RR interval
-40
Mean RR interval
Speckle tracking
Comparison of Strain values in Different
studies
Mean
Strain
(%)
Augusti
ne et
al.(BSE
2009)
Stefani L Tong C
et al.
et al.
Cardova (2008)
sc US
2009
Pirat B
at al.
Cardiol
(2006)
Teske et
al. JASE
(2008)
Luc
Mertens
Nature
Reviews
2010
RV basal
Free wall
-27.817±
-28.69±
-33.802±
4.62
7.03
-22.8±
10.2
-19. ±6
5.77
-44.8±
10.2
-25.21±
4.97
-32.69±
5.9
-26.9±
5.3
-24.4±
7.7
-27. ±6
-24.86±
8.15
-28.1±
8.15
-27.6±
6.7
-36+2
N 109
RV Mid
Free wall
-27.179±
5.6
RV
Apical
Free wall
-21.568±
7.94
Basal to apical reduction in strain
Apiacal to basal reduction in strain
RV Global Function vs EF
10
Strain = .08186 - .0047 x EF
Correlation: r = -.6902
0
- 10
- 20
95%
confid..
Regression
- 30
- 40
20
30
40
50
60
70
RV ejection fraction -% (MRI)
F. Rademakers JACC, 2000
DTI vs. STE
A. TDI – derived strain
B. STE derived strain
Jurcut R et al. Eur.J.of Echo , 2, 2010
Comparison between 2D strain and
TDI
Teske . JASE 2008
RV function and AH
• RV performance in hypertensive's in not well
evidenced
• Bernheim’s syndrome (Selzer,1955, Russek 1950)
↑ peripheral venous pressure
↑RA pressure
LV hypertrophy
•
LV hypertrophy
RIGHT HEART FAILURE
RV function and AH
RV pressure
RV-LV interrelationship
Right ventricle
Pulmonary vasonstriction ↑
Enhanced SNS activity, ↑plasma CA,
↑angiontesin
Alterered metabolism
LV hypertrophy ,LV pressure
LV diastolic dysfunction
AP pressure↑
LV pressure ↑
RV volume
RV enddiast pressure↑ LV enddiast. pressure ↑
W. Motz. Internist,2004
RV hypertrophy
RV diastolic dysfunction
LV hypertrophy
LV diastolic dysfunction
RV function and AH
• RV EF % in hypertensive's with LVH is higher than
without LVH
(Olivari, Circulation,1978)
• Hypertensive pts have higher RV pressure than normal's
and RV performance is lower RV EF %
(J. Ferlinz, Circulation,1980)
• Invasive studies showed the pathology of pulmonary
circulation in pts with AH
(R. Fagard, JACC,1998)
• MRI study of RV remodelling in systemic hypertension
(Pedrinelli, Heart, July 2011)
RV function and AH
• Echocardiographyc studies ( Myslinski, 1998,
Akkos1999) about RV function and diastolic parameter
• AH is associated to RV longitudinal diastolic dysfunction
– pulsed TDI imaging
(S. Cicala, EJEcho, 2002)
• TDI provide quantitative analysis of RV alteration in
hypertensive's
(Tumuklu, AJE, 2007)
 Abnormal RV mechanic of IVS in hypertensive’s
( R. Pedrinelli , EJ Echo , 2010)
The impact of arterial hypertension
on right ventricular deformation
K Hristova1, A La Gerche2, Tz Katova1,
V Kostova1, Y Simova1,
1National
Heart Hospital - Sofia - Bulgaria,
2Catholic University of Leuven - Leuven - Belgium
• First STE study with hypertensive patients
Purpose :
•
HT has long been known to be a major risk factor for heart failure .
• The Framingham study provides some of the best evidence with
regard to the association between BP and HF. Around 90% of those
developing HF had aprior history of HT. This is three times the risk
seen in normotensives.
• HT is the most important modifiable factor in congestive cardiac
failure. However, almost 40% of episodes are associated with
diastolic dysfunction.
• Diastolic dysfunction ranges from a failure of end diastolic volume to
rise appropriately with exercise to that of overt diastolic HF
Aim:
The aim of our study was to determine the effect
of arterial hypertension and hypertensive
cardiac remodelling on right ventricular (RV)
function, using vector velocity echocardiography
to determine strain and strain rate.
Methods:
•
•
40 patients with arterial hypertension and left ventricular
hypertrophy (LVH group) with 20 healthy control subjects.
None of the hypertensive patients had symptomatic heart failure.
•
Apical four-chamber images were acquired (frame rate 74 ± 6
frames/s) with Aloka alfa- 10 and analyzed offline on Syngo US
Workplace 2007, Siemens AG . in order to extract the strain (rate)
curves.
From these, the maximal systolic strain (PSS) and peak strain
rate (PSR) on right and left ventricle were derived, using vector
velocity imaging (VVI) software. Tricuspid annular plane systolic
excursion (TAPSE) and as well as mid-apical and basal peak
ejection strain (S) and strain rate (SR) of the RV free wall were
measured
2DSTE
2DSTE
2DSTE - VVI
2DSTE- VVI
Results:
Demographic and baseline data of study population
Age
Height (cm)
Weight (kg)
Gender
AH - groups
Normals
68.9±13
31±5
173.14±9.45
174± 4
82.74±13 .8*
30M/10F
67±11
12M/8F
BSA( m2)
1.99± 0.21
1.8±0.11
HR (bpm)
67.5±12.4
78.8±3.4
SBP (mmHg)
156.8±13,7*
115±12
DBP (mmHg)
87±12*
67±9
Results:
Echocardiographic data of the study population
AH - groups
Normals
LVEF (%)
62±6.3
66±10,1
LVEDD (mm)
48.7±8.7
45±4,4
LVEDD/BSA (mm/m2)
24.47±4.7
25±3,7
LVEDV (ml
109.6±31.10*
81.11±25*
LVEDV/BSA (ml/m2)
54.77±14.8*
45.06±12.3*
LVESV (ml)
48.71±13.60*
38.37±13*
LVESV/BSA (ml/m2)
24.48±6.7
21.31±6.8
LVSV (ml)
60.56±10
61.46±16
LVSV/BSA (ml/m2)
30.43±5.5
34.14±8,2
mass (g)
264.30±.765*
173±11.3
mass index(g/m2)
132.3±30.9*
92.02±5.6
E/ A
0. 75 ± 0. 41*
1. 87 ± 0.48
TAPSE (mm)
21 ± 2,9 mm
23 ± 2,2 mm
Results :
Global strain / Normals
rate
(1)
AH - group
(2)
p-value
(2) vs(1)
PeakSSLV
- 19.69±1.82
16.4 ± 3.14
p=0.56
PeakSS RV
-15, 5 ± 2, 3
-10.03 ±4, 5 * p<0.01
PeakSRRV
1.75
0.45 *
p<0.01
Results:
Regional right ventricular myocardial function
Peak Systolic Strain – RV
Basal level
Middle level
Apical level
Normals
-14.03 ± 3.78
-17.23± 2.23
. - 12.3 ±2.56
AH group
- 12, 31 ±3, 87
- 11, 24 ± 3.2*
- 7, 87±2.34*
Conclusion:
• The present study demonstrates that
measures of RV deformation are
reduced in patients with LVH
secondary to hypertension.
• Thus, this data suggests that LVH may
cause early sub-clinical RV dysfunction
even in the absence of overt diastolic
heart failure.
Take home message :
▶ RV function is an important parameter in
cardiac disease
▶ 2DE is a relatively feasible method to
assess RV dysfunction in clinical
practice
▶Several new echocardiographic
techniques such as TDI, SRI, RT3DE may
give us further information in assessing
RV function
“ Don`t
forget to check your
Facebook account
right
before leaving,
ventricle
you might get a new
friend request ! ”
Prognosis
Mark Elliot Zuckerberg
Thank you
for your attention!
RV Systolic Function
LONGITUDINAL vs RADIAL FUNCTION
Longitudinal vs radial RV systolic velocities
in young (16-40 y, n=19) and old normals (41-76 y, n=13)
systolic velocity (cm/s)
16
14
young normals
12
old normals
*p=0.01
**p=0.005
**
10
8
6
4
*
2
0
RV radial systolic
motion
RV longitudinal
systolic motion
Normal RV Regional Function
RV DIASTOLIC FUNCTION
Early diastolic (e) velocities in young (16-40y) and old normals
(41-76y)
early diastolic velocity (cm/s)
16
*
*
young normals
old normals
*
12
* p<0.05
*
8
*
4
0
Annulus
Basal
Medial
Apical
LAX